Case Study: During the failed resuscitation attempt of a premature newborn in a neonatal intensive care unit (NICU) a nurse discovered the child was receiving 100 times the proper dose of heparin. An immediate review of all 35 NICU patients revealed three others had heparin IV overdoses running. These were stopped and those patients suffered no adverse effects. An immediate investigation by the hospital’s Sentinel Event Rapid Response Team discovered a series of missteps that unfortunately aligned despite the presence of multiple preventative systems and processes including computerized physician order entry (CPOE). The critical error turned out to be an erroneous heparin overdose order in a “Neonatal Admissions” order set. Order sets that include medication orders at this hospital must be approved by the Pharmacy and Therapeutics Committee (P&T). P&T had previously approved the order set, but on the morning of the incident the Medical Director of the NICU had called IT and requested that several non-pharmacy orders immediately be added to the order set. The purpose of these new orders was to capture additional data needed for a monthly neonatology quality report that is electronically sent to a national database and used for quality benchmarking. The clinical IT analyst did not think the order set needed to go back to P&T because there were no new pharmacy orders. However, this EMR requires the analyst to re-enter the entire order set when making any changes. The analyst made a decimal point error when keying in the Heparin order. No other clinician reviewed, tested or reviewed the change.
- Inaccurate or inconsistent clinical content in an EMR is a risk to patient safety and automation can propagate such errors to multiple patients before being discovered and corrected
Physicians and their staff will develop or customize clinical content for parts of their EMR such as order sets, documentation templates, physician orders and discharge instructions. This case serves as a brutal reminder for the need to be very attentive to the accuracy of clinical content in an EMR. The tragic outcome in this case was initiated by a type of human error (a “typo”) that can be anticipated and prevented by oversight processes.
- Physicians should oversee the processes used to manage and monitor the development of clinical content
Physicians will usually be called on to be the “authors” of EMR clinical content for items they are most knowledgeable about such as the documentation templates and order sets they will use. Ideally the physician will develop content that is evidence-based and collaborate with others in the practice to avoid conflicting content and to reduce variations in care. But physicians should also oversee the processes used to manage and monitor the development of other clinical content as well. Similar to the hospital P&T committee, a physician or physician group should review and approve new or changed content before it is put into their EMR. Content should also be reviewed by the authors at least annually to keep it up-to-date.
- Physicians should work with their EMR vendor to assure that the clinical content in their EMR meets the emerging state and federal vocabulary standards for content
Vocabulary standards define how an EMR “encodes” clinical data which facilitates the ability of EMRs to reliably exchange that data with other systems. In other words, if two EMRs use the same definition of “Gestational Age” and encode that measurement in the same way, those EMRs will be able to exchange that data (“talk” with each other) reliably. In this case the neonatologists were adding an order to capture “Gestational Age” in the EMR to meet a new vocabulary standard determined by their specialty’s national quality benchmarking entity. Some state and federal vocabulary standards exist, but more are forthcoming with the HITECH “meaningful use” requirements driving them forward.